Primary health care:
through which medical services are provided to the general population and to
vulnerable groups (pregnant and lactating mothers and children under five years
of age).

Curative care services:
where sick people find medical treatment.

Nutrition strategies

Before 1992, ad hoc programmes addressed the problem of
malnutrition. Following the International Conference on Nutrition (ICN), held in
Rome in December 1992 and sponsored by FAO and WHO, nutrition programmes in
Egypt have been enhanced.

Egypt presented a country paper at the conference and took
part in post-ICN condensed nutrition activities. A ministerial decree of 1994
formulated a high-level inter-ministerial committee representing the ministries
of agriculture, health, planning, information, supply, education and academia.
The outcome was the development of the Egyptian National Strategy for Nutrition,
which has nine main policy areas. Each policy area includes a problem statement,
a goal, measurable objectives, actions, authorities responsible for undertaking
the different activities, resources, legislation (if required), and monitoring
and evaluation indicators.

The main policy areas are:

incorporating nutrition objectives, considerations and components into development
policies and programmes;

improving household food security;

protecting consumers through improved food quality and safety;

preventing and managing infectious diseases;

promoting breastfeeding;

caring for the socio-economically deprived and nutritionally vulnerable;

preventing and controlling specific micronutrient deficiencies;

promoting appropriate diets and healthy lifestyles;

assessing, analysing and monitoring nutrition situations.

Most of the programmes directed at improving the nutritional
status of the population fell under the umbrella of this national
strategy.

Programmes to improve food security

In addition to health/nutrition care, the availability of food
items is also very important in efforts to improve nutrition status. The
following are some of the main programmes aimed at increasing food availability
in Egypt.

Food ration and subsidy programmes

The main objective of the food subsidy programme was to
improve household food security and to prevent malnutrition and chronic energy
deficiency. The current food rationing programme was established more than 50
years ago. In addition to price subsidies, specific forms of price intervention
include market interventions in the form of subsidized food imports sold through
the existing cooperative system. The most recent examples of this are meat
imports from the Sudan, which are sold at less than half the price of locally
produced meat. According to the present rationing programme, each individual
receives - through the family card - a monthly ration of sugar, tea, oil,
lentils, broad beans, rice and macaroni that meets a significant proportion of
the familys needs. The subsidy of wheat bread is the most important
component of this programme, but the food subsidy programme has several
drawbacks and constraints as the cost of food price subsidies represents a
serious drain on Egypts national economy and constitutes a major block to
the development programme.

Programmes to increase food production

As part of a national land reclamation project, the government
has initiated projects all over Egypt. These include the Toshka project in Upper
Egypt, which was started in January 1997 and aims to double the area of arable
land in Egypt within a period of 15 years. The projects estimated cost was
about US$86.5 billion to cover the 20 years from 1997 to 2017.

Programmes to improve nutritional status and to prevent and
control malnutrition and morbidity

Programmes to prevent diet-related
NCDs

Many programmes have been directed at improving the
nutritional status of the Egyptian population and preventing NCDs. These
programmes included the following strategies:

Nutrition
education: Community nutrition education was carried out through health
facilities, schools, non-governmental organizations (NGOs) and the media with
the aims of increasing the populations awareness of the programme,
enhancing its knowledge and modifying its nutritional behaviours.

Food-based dietary
guidelines: With support from the United Nations Childrens Fund
(UNICEF), NNI produced food-based dietary guidelines for Egypt. These guidelines
are directed at educated people, nutrition educators in the health sectors, NGOs
and others. They include simple practical messages for healthy eating and
lifestyles.

Nutrition capacity
building: NNI and MOHP are building capacity through training programmes for
health providers, physicians, nurses and community workers.

Specialized clinics:
NNI has set up specialized clinics for the prevention, early detection and
management of nutritional diseases, particularly obesity, its co-morbidities and
stunting.

Programmes for improving nutritional
status

Many programmes directed at improving the nutritional status
of Egyptian populations have been carried out over the last 20 years. The
following paragraphs describe some of these.

The national programme for supporting breastfeeding
practices: Exclusive breastfeeding for the first six months of age,
continuing breastfeeding up to two years of age, and healthy complementary
feeding practices were the main thrusts of breastfeeding promotion activities.
Among the many activities implemented to achieve these aims were the formulation
of a national committee for the promotion of breastfeeding practices, the
establishment of a national policy to support and encourage breastfeeding,
implementation of the Baby-Friendly Hospital Initiative in 120 maternity health
facilities, and implementation of the international code for the marketing of
breastmilk substitutes.

Child Survival and Integrated Management of Childhood
Illness: MOHP conducted many projects to improve the health and nutrition
status of children under five years of age; these included the Control
Diarrhoeal Diseases Programme, Child Survival (1985 to 1995) and Integrated
Management of Childhood Illness (1995 to 2005).

The national programme for improving the nutritional status
of school-age children: The Ministry of Education implemented school feeding
programmes to enhance schoolchildrens physical and mental development. The
programmes include the following:

Iron-fortified
biscuits: one packet of 80 g biscuits fortified with iron salt is given to each
child in primary schools.

The School Pie Programme: the
ministries of education and agriculture provide pies on 110 days a year to half
a million primary schoolchildren in seven governorates (Fayoum, Monofia,
Behaira, Port Said, North Sinai, Damitta and Beni Swef). The World Food
Programme (WFP) contributes to this programme by extending the period of meal
distributions to 150 days.

Cooked meals: The main target
groups for this are handicapped students.

Cold/dry meals: The main
target groups for these are students in secondary, industrial, agricultural,
technical and sports schools.

The number of students involved in these programmes increased
from 3 019 130 in 1991/1992 to 11 210 258 in 2004/2005. Government contributions
and external aid increased from LE 35 806 594 in 1991/1992 to LE 353 600 000 in
2004/2005.

Programmes for the prevention and control of
micronutrient deficiencies

The National Programme for the Prevention and Control of IDA: Among
MOHPs activities directed at preventing and controlling IDA are:

health and nutrition education;

iron supplementation to pregnant women;

iron supplementation to adolescents and schoolchildren (primary and secondary);

programmes to prevent and control infection and infestation.

The National Programme for the Prevention and Control of
IDD: With support from UNICEF, MOHP and NNI have implemented many programmes
to prevent IDD, which is a public health problem in Egypt. These programmes
include:

iodized oil
supplementation in New Valley governorate (which has the highest IDD
prevalence);

formation of the National IDD
Committee in1993;

the universal salt iodization
programme, launched by MOHP in 1996 with the support of UNICEF;

four social marketing
campaigns to promote iodized salt, which were conducted by NNI, MOHP and UNICEF
with the aim of increasing household-level use of iodized salt in governorates
where this was low - Gharbia, Fayoum, Quena and Assuit. As a result,
household-level use of iodized salt rose from 56 percent in 2000 to 79 percent
in 2003 (EIDHS, 2003);

early detection of neonatal
hypothyroidism through a neonatal screening programme that aims to test every
child before it reaches one week of age.

The National Programme for the Prevention and Control of Vitamin A Deficiency:
After NNI had conducted its national survey of vitamin A status, a national
plan to eliminate VAD was implemented. This plan involved the following activities:

Egypt is a developing country that is facing the double burden
of malnutrition. Over recent years, annual per capita income has increased from
LE 4 822.4 in 1998/1999, to LE 5 537.6 in 2000/2001 and to LE 5 652.8 in
2002/2003.

Health indicators have also improved over the last 25 years.
The under-five mortality rate decreased from 102 per 1 000 live births in 1980
to 1985, to 46 in 1998 to 2003. With infant mortality decreasing from 73 to 38
over the same period. These data indicate that childhood mortality is becoming
concentrated in early infancy. Overall, 88 percent of children are immunized
against all major preventable childhood diseases. Life expectancy has increased,
for males from 52.7 years in 1976 to 67.9 in 2003, and for females from 57.7
years in 1976 to 72.3 in 2003.

The changed consumption patterns of the Egyptian population
during the last two decades can be explained as reflecting changes in
socio-economic status, changes in feeding habits, urbanization and
globalization. The dietary changes that have occurred in Egypt have been
associated with increasing proportions of energy-dense foods and saturated fat.
Food patterns have changed towards increasing intakes of fats and oils, high-fat
products, sugar, meat and refined carbohydrates, and decreasing cereal
consumption.

The total energy intake declined from 3 057 kcal in 1981 to 2
460 kcal in 2000, and the mean protein intake increased from 88.7 g to 91.5 g.
In 1981, cereals contributed 61.2 percent of total energy intake, and animal
protein only 8.1 percent. In 2000, cereals contribution had declined to
52.0 percent, while animal proteins had increased to 20 percent. Animal
proteins contribution to total protein intake also increased, from 27.7
percent in 1981 to 35.5 percent in 2000. This represents a significant increase
in consumption of animal protein, while the contributions of vegetarian food
groups to energy and protein intakes are decreasing; this may play a role in the
emergence of diet-related chronic diseases in Egypt.

Although mothers total energy intake decreased from 2
602 kcal in 2000 to 1 995 kcal in 2004, this did not seem to have any influence
on the prevalence of obesity among females. This can be explained by the
complexity of obesity pathogenesis. Most of the mothers - more than 90 percent -
did not practice any regular physical activity.

Food prices and availability have influenced the food
consumption of Egyptian populations. Increased income leads to people increasing
their consumption of meat and animal protein; after prices increased rapidly
following devaluation of the Egyptian pound in 2001, the consumption of all food
groups decreased in 2004.

The food adequacy data from NNI national surveys show that the
percentage of children receiving more than 100 percent of their energy RDAs
increased from about 14 percent in 1995 to about 46.9 percent in 2000. These
data, when added to the decrease in physical activity, explain the high
prevalence of obesity in adolescence.

Although data show that about 90 percent of children and 70
percent of mothers consume more than 100 percent of the RDA for iron, the
prevalence of anaemia in Egypt is still very high. This could be because most of
the iron consumed is of plant origin, which decreases the bioavailability of
iron.

Changing life styles, with more psychological stress, less
physical activity and more high-density food, and changing eating habits, such
as eating heavy meals late at night, are leading to increased prevalence of
overweight and obesity among Egyptian populations. This in turn is leading to
increased prevalence of diet-related chronic NCDs - diabetes, hypertension and
certain types of cancer. The alarming results are that diet-related diseases are
becoming more prevalent among younger age groups.

It is evident that future surveys should standardize their
methodologies, have unified guidelines and be implemented regularly. This will
make it easier to analyse, compare and track changes over time.

Changing the conceptual framework for implementing nutrition
education programmes so that more attention is paid to raising Egyptians
nutrition awareness could help the prevention of diet-related diseases and their
consequences. Such programmes must target adolescents and young adults,
especially females, in order to reduce the high prevalence of NCDs in Egypt.
Micronutrient deficiencies, especially IDA, still need strategies such as food
fortification and nutrition education to increase the bioavailability of iron in
foods. It is also recommended that distribution and application of the existing
food-based dietary guidelines be strengthened.

Obstacles and constraints faced by this
report

The following challenges were encountered during the
preparation of this report:

Raw data from most
NNI and ARC surveys were not available, so data had to be obtained from the
published reports.

The NNI and ARC surveys used
different types of analysis as regards RDAs, food composition tables and use of
the truncated method (removing data pertaining to consumption of > 100
percent RDA). Differences in methodology made it very difficult to compare both
sets of data.

The dietary consumption
surveys conducted by NNI had differing objectives and target groups, making it
difficult to derive trends in food consumption patterns.

Summary of the capacity building
needed to improve nutritional status in Egypt

Institutional needs

National nutrition policy

There is a great need to implement a national nutrition policy
with objectives that are modified according to changes in food patterns and food
habits. Healthy eating and healthy lifestyles should be addressed in all health
facilities and school curricula.

New component in primary health care to address obesity
and diet-related NCDs

The role of the primary health care unit in preventing and
treating obesity and NCDs must be addressed over the coming years, as the
prevalence of diet-related diseases is increasing.

Strengthening of the nutrition surveillance
system

A nutrition surveillance system was established in Egypt
between 1995 and 1997. There is a great need to redesign and strengthen this
system for the early detection and proper management of malnutrition
disorders.

Capacity building and training needs

Improving nutrition status requires a well-trained health
staff who are capable of communicating with communities to spread information
about healthy food and to educate people on the prevention of NCDs. There should
be continuous training programmes for health staff, with emphasis on intra- and
intersectoral collaboration.

Communication, education and advocacy
activities

Communication
programmes are important in supporting strategies to prevent nutrient
deficiencies. Information on causes, consequences and measures to control and
prevent IDA, IDD and VAD should be disseminated through mother-and-child health
centres, primary and secondary schools and the mass media.

Education and communication
programmes are needed to raise awareness of the risks of obesity and
diet-related NCDs and to change the health and nutrition behaviour of women.
Such programmes should be implemented for adolescent girls in schools and at
mother-and-child health centres.

Galal, O. 1987.The Collaborative Research
Support Program (CRSP) on Food Intake and Human Function. Final
Report. Grant No. Dan - 1309-G-SS-1070-00. Washington, DC, United States
Agency for International Development.

Hassan, H.A., Gargas, S.M., Abdel Galil, A. &
Darwish, A.H. 2001.Focusing on the health requirements and style
of living to improve the health of elderly people in different cultural sectors
in Egypt. Final Report. Cairo, NNI.